HEALTH COSTS AND BUDGET

ESE’s commitment to empowerment and engagement of citizens in processes for planning, implementation and evaluation of legislation, budgets and services under the social accountability and legal empowerment approach was crowned with the formation of the European Community of Practitioners on Accountability and Social Action in Health – COPASAH. On the account of absence of any relevant data, a survey research was conducted on utilization of primary healthcare services among Roma people and populations living in rural areas and about environmental risks and impact thereof on health and living conditions for Roma. For that purpose, we applied the social and behavioural change methodology to practicing healthy lifestyles and life-cycle immunization of adult population. We continued to gather evidence on citizens’ needs in respect to facilitated access to justice, focusing on detailed analysis of women who have suffered domestic violence, which means that, in addition to ensuring resolution of their legal needs, efforts were also geared towards issues related to child support and economic independence of these women. Significant effort was invested in developing ESE’s social enterprise branded as POGON. As regards taking action in cases of domestic violence, we cooperated with police officers and inspectors taking initial action in such cases. On the account of its efforts for promotion of fiscal transparency, ESE became part of the Europe Beneficial Ownership Leadership Group that have made significant contribution for improving civic engagement in the country and will continue to work together on promoting civic engagement across Europe (under the OGP process).

In this period as well, ESE remained committed to promoting civic empowerment and engagement in processes for planning, implementation and evaluation of legislation, budgets and services under the social accountability and legal empowerment approach. For that purpose, we designed plans for continuous capacity building of staff members at partner Roma organizations, delivered training and advanced the process of mapping Roma communities for increased and holistic engagement of citizens in decision-making processes by developing additional criteria for community mapping. Another milestone in this period concerns training delivered by experts from the University of Seville, Spain, focusing on work in the field of improving Roma mental health, which is the first of this type. Capacity building work with public institutions in this period concerned the ability to engage and involve citizens in their operation. Cooperation with HOPS continued in the form of support to their efforts on access to public information; gathering data on the amount of funds collected on the basis of excises levied on beer, ethyl alcohol and cigarettes and designated for promotion of citizens’ health; gathering data on funds collected on the basis of custom duties, as well as fees for import, process and sales of cannabis and its products and how these funds had been spent. In cooperation with the Employment Service Agency, the Ministry of Labour and Social Policy and four partner organizations, we worked on promoting transparency and civic participation in the labour sector, and we worked on improving quality of and access to employment services for citizens, with focus on vulnerable groups.

In response to the global pandemic and the consequent state of emergency, efforts in 2021 were focused on assessing needs of Roma communities related to timely response and recovery at times of crisis, notably by conducting a survey research among 2 527 households in Roma communities in four municipalities (Shuto Orizari, Prilep, Gjorche Petrov and Karposh). This endeavour resulted in documentation of key problems faced by Roma communities and their ability for timely response and recovery at times of crisis, i.e. 58 photographs with text message (PhotoVoice). We formed three community councils that would work on developing response and recovery plans at times of crisis for Roma communities through participatory and proactive action (Shuto Orizari, Prilep, Gjorche Petrov and Karposh). This effort resulted in development of four such plans at local level.

In 2021 we formed the COPASAH Europe Network comprised of 16 civil society organizations from Macedonia, Serbia, Bulgaria, Romania, Hungary and Albania. The network is envisaged to serve as platform for building civil society capacity to apply the social accountability and legal empowerment methodologies in their work on improving the exercise of human rights by marginalized communities. This was followed by development of the network’s strategic operation in the same year. In the period 2022-2023, we worked on building capacity of domestic and regional civil society organizations, i.e. COPASAH Europe Network, whose secretariat is managed by ESE. We conducted a number of capacity building activities for network members, but also worked on popularizing the concepts applied by this network. In particular, we developed the network’s communication strategy together with other member organizations from North Macedonia, Montenegro, Romania and Albania and exchanged experiences on work with vulnerable groups of citizens. We actively participated in consultations organized around COPASAH Global’s Strategic Plan. Moreover, we delivered two trainings: one related to application of the social accountability methodology intended for civil society organizations from the country, Serbia, Montenegro and Romania, and another training on impact assessment methodology relating to environmental impact on the population’s living conditions and health, with special focus on vulnerable groups of citizens. Two training modules were developed and posted on the network’s website for interested parties to use them. To actualize particular issues of importance, in cooperation with practitioners from around the world, the network organized three webinars on topics such as: “Impact of the Crisis on Health Services for Women, with Emphasis on Marginalized Groups of Women”; “Creating Opportunities for Stakeholder Participation in Responding to Emergencies in the Region” and “Strategic Litigation”. Finally, we designed and published two newsletters of COPASAH Europe.

In 2022, we committed to data collection and conducting survey research in Roma and rural communities on utilization of primary healthcare service by Roma and populations living in rural areas. More specifically, the research focus was put on health of mothers and children, as well as mental health. Findings from the research conducted in Roma communities were presented in the publication “When Life on the Margins of Society Determines Health: Access to Primary Healthcare for Roma People in the Republic of North Macedonia”, while findings from the research conducted in rural areas were published in the publication “When the Place of Residence Determines Health: Access to Primary Healthcare for People Living in Rural Areas in the Republic of North Macedonia”. The research targeting mental health relied on cooperation with renowned experts on Roma mental health from Europe. We collected data on environmental risks and their impact on living conditions and health of Roma people and tested utility and applicability of WHO’s Guide on Engaging Roma Communities in Contact Tracing. Findings from the survey research on environmental risks to Roma health are presented in the publication “Life on the Periphery: Study on Exposure to and Impact of Ecological Risks on Living Conditions and Health of Roma”.

We continued activities on monitoring implementation of preventive healthcare programs. A 2021 research study focused on consequences created by inconsistent implementation of uterine cancer screening relative to women’s mortality and quality of life, as well as costs falling on the burden of women and the state. Research findings and recommendations to promote screening activities are contained in the publication “Cost of the Failure to Organize Uterine Cancer Screenings”. In 2022, we developed three monitoring reports for two preventive healthcare programs (uterine and breast cancer screening) and one monitoring report for the Program for Active Health Protection of Women and Children, followed by pilot research in 2023 focusing on functionality of the electronic system for scheduling gynaecological examinations with PAP test, which is part of the Program on Uterine Cancer Screening, including two media releases (one video and one printed story) underlining inconsistencies in implementation of preventive healthcare programs, which were submitted to competent authorities together with a request for improved performance of these programs.

We participated and contributed to various important national processes and international events. At national level, we participated in development of the Strategy on Roma Inclusion 2022–2030, as well as 2023 and 2024 Programs for Active Health Protection of Mothers and Children. Furthermore, we participated at conferences organized for promotion of the Program or Uterine Cancer Screening to improve the healthcare system in North Macedonia and made significant contribution thereto. As member of the European Roma Health Network, we contributed in development of recommendations aimed to improve implementation of Roma Inclusion Strategies by EU member-states and candidate countries. We developed a shadow report to the Convention on the Rights of the Child relating to health of children and pregnant women, and shadow report to the UN Universal Periodic Review relating to the right to health and access to healthcare for Roma people, women and rural populations.

In 2023, efforts were dedicated to advancing the population’s health by applying social and behavioural change methodologies for practicing healthy lifestyles and life-cycle immunization of the adult population. In that vein, we trained 200 health workers (medical doctors, nurses and pharmacists) to apply these methods in their work to promote healthy lifestyles and increase coverage of their patients with vaccines. We delivered health education to 843 citizens on healthy lifestyles and importance of life-cycle immunization among adults, by applying the social and behavioural change methodologies. At the same time, we distributed 2 043 health education materials in the form of mini posters with content on healthy lifestyles and need for regular immunization of the adult population. A total of 7 966 SMS messages were sent to citizens and health workers featuring educational information aimed at promoting healthy lifestyles and regular immunization of the adult population. In the same vein, we organized a workshop with representatives from healthcare institutions to identify barriers to higher vaccine coverage among children and adult populations and designed measures to improve the overall immunization rate.

We worked on promoting health and healthcare of Roma population. For that purpose, efforts were made to identify barriers and problems faced by Roma women when accessing reproductive health services, as well as barriers and problems faced by mothers and children in Roma communities when accessing preventive healthcare service, followed by publication titled “Status of Reproductive Health and Health of Mothers and Children in Roma Communities”. We provided assistance in drafting written advocacy demands for improving access to primary healthcare for Roma in Shuto Orizari and advocated before the Deputy Prime Minister, Minister of Health and Chairman of the Health Committee at the Parliament for increased coverage of Roma population with COVID-19 vaccines in the early rollout of the nation-wide vaccination effort. In 2023, expert support was secured for partner Roma organizations for creating Roma Community Scorecards used to assess access to and quality of primary healthcare and preventive healthcare for women, mothers and children. Moreover, we provided assistance for development of local advocacy strategy focused on improving access to primary healthcare for Roma and improving access to preventive healthcare for women, mothers and children. This was followed by advocacy activities aimed at improving healthcare services for citizens in the Municipality of Shuto Orizari, which included a petition and presentation of demands for competent institutions to increase the number of healthcare services offered at the Policlinic in Shuto Orizari and to increase the number of registered general physicians, specialist and consultation healthcare services, X-ray and laboratory cabinets. We worked on enhancing capacity of partner Roma organizations to conduct a research in Roma communities by organizing a separate training for that purpose.

We worked on building capacity of civil society organizations, paralegals and young lawyers to resolve issues relating to access to justice for vulnerable groups of citizens. Two e-training modules were designed and intended to be used by paralegals, followed by training of 12 young lawyers to work on resolution of legal problems relating to domestic violence. We contributed to development of the Global Legal Empowerment Network – NAMATI’s Gender-Responsive Strategy on Access to Justice, notably by facilitating meetings with civil society representatives at national and regional level (Greece, Albania, Bulgaria and Bosnia and Herzegovina) to discuss priority areas for promotion of women’s status, opportunities for joint learning (capacity building) and advocacy at national, regional and international level. In cooperation with the Macedonian Association of Young Lawyers, we contributed to capacity building efforts for civil society organizations working in rural areas around issues relating to the UN Convention on Eliminating All Forms of Discrimination Against Women, especially by organizing training and mentorship for development of shadow report on actual status of women in rural areas.

In this period we continued to gather evidence on the needs of citizens in relation to facilitated access to justice. In 2021, we developed the report on implementation of SDG 16.3 based on previously designed set of indicators for monitoring state-of-play relating to the rule of law and equal access to justice. We developed a cost and benefit analysis on provision of free legal aid in 2021. With help from women affected by this issue we were able to identify costs incurred for initiating and leading necessary court proceedings. Another subject of analysis was child support, i.e. the need for such support and the amount set by courts. We expanded the field of research and started collecting data on loss of jobs and decreased earnings by women, health-related costs, costs relating to change of residence and other expenses faced by women as a result of domestic violence. In 2022, another cost and benefit analysis was focused on free legal aid for women who have suffered domestic violence, completing the cycle of this type of annual analyses initiated back in 2017.

In 2023, ESE’s work accounted for significant contribution in reporting state-of-affairs at international level. More specifically, we submitted a shadow report to the UN Universal Periodic Review covering a myriad of issues, including violence against women and domestic violence, access to primary healthcare for vulnerable groups of citizens such as women, Roma, rural populations. A written submission was made towards the report “The Promise of Legal Empowerment in Advancing Access to Justice for All” developed by the Un Special Rapporteur on Independence of Judges and Attorneys. Another milestone contribution was made in respect to the Word Bank’s  2023 special report “Women, Business and the Law”, including written summary of the status of women in relation to gender-based violence, marriage and family, property relations, labour market, etc.

Work continued on providing necessary legal and psychological support for women who have suffered domestic violence, whereby 500 persons were provided legal aid and approximately 150 persons benefited from psychological support. Court representation was secured for 24 women to initiate and lead necessary court proceedings. In 2021, upgrades were made to the internet platform for legal advice to women who have suffered domestic violence – ASK FOR ADVICE – www.pobarajsovet.mk, by integrating a feature for written submissions necessary for resolution of legal problems related to domestic violence, making the platform available in Roma and Albanian language and enriching its content with videos on civil and criminal court proceedings for protection against domestic violence. At the same time, we organized a comprehensive campaign to raise public awareness, especially among women, about the nature of domestic violence and law-mandated protection mechanisms, and produced a short documentary video “Domestic Violence is Cruel Reality for Many Women and Children”, intended to actualize the issue of violence and the need for assistance and support for women who have suffered domestic violence.

We engaged in advocacy at regional and national level for interests of women who have suffered domestic violence. A shadow report was developed to the Istanbul Convention, in cooperation with the Coalition MARGINS, Open Gate and the University of Edinburgh’s International Law Initiative. ESE staff participated in round table discussions organized by the Monitoring Mechanism of the Istanbul Convention to evaluate action taken by state institutions and judicial authorities. As part of the national process within the Open Government Partnership, we advocated for development of rulebooks for data collection on gender-based violence and for adoption of separate commitment under OGP NAP 2024–2026 to intensify activities by competent ministries in the field of prevention and awareness raising among the general and expert public. We contributed in the process of amending the Criminal Code and changing standard operating procedures at social work centres in domestic violence cases. At the same time, we worked with practitioners that work on domestic violence cases. Two videos for practitioners were produced and focused on the civil protection system, featuring statements by civil court judge and attorney-at-law that underline key aspects of proceedings for issuing temporary protection measures and the criminal protection system, as well as statements by criminal court judge and MoI representative that underline key aspects of criminal proceedings led by the police, prosecution offices and courts. This was accompanied by development of e-training course for practitioners, intended to enhance their knowledge and skills for enforcement of national and international legislation when working on domestic violence and violence against women cases. A forum was organized in 2022 with representatives from the Ministry of Justice and basic court judges from Skopje, Veles and Radovish, to improve civil legal protection of women. In 2023, local forums were organized with practitioners from basic civil courts, social work centres, Ministry of Justice’s regional offices for free legal aid and civil society organizations from Kumanovo, Prilep and Bitola, to improve civil legal protection of women who have suffered domestic violence.

In 2021, we developed an analysis of police actions in domestic violence cases, based on expert interviews with 48 police officers from all 8 sectors of internal affairs, and 12 women who had previous experience with the police when reporting domestic violence, including recommendations aimed at improving police actions, i.e. conducting investigations and issuing urgent protection measures in domestic violence cases. Consequently, we organized two trainings for police inspectors and uniformed police offices to enhance their knowledge and skills on risk assessment and issuing urgent protection measures for women, as well as more efficient criminal proceedings for criminal offences relating to domestic violence. At the request of SEESAK, ESE made a significant contribution to the regional initiative for reduced use of firearms in domestic violence cases.

Together with women who have suffered domestic violence, we worked on their economic empowerment and fundraising for provision of legal aid through the social enterprise POGON. We conducted a needs analysis relating to education of women, which served as baseline for organization of several trainings for women to acquire skills, including business development and management. A milestone achievement in this endeavour concerns POGON’s outreach to 410 local artisans from North Macedonia and five countries in the region, including cooperation agreements signed with 15 artisans. Hence, POGON now includes 46 artisans and markets more than 394 different types of products. Revenue collected from this effort exceeded MKD 100 000, four times the amount collected in 2021. POGON as brand and its products, including those crafted by women who have suffered domestic violence, have reached out to 484 885 persons in North Macedonia. Being a unique sales platform, POGON contributed to economic empowerment of 16 women who have suffered domestic violence. In particular, we enabled five women who have suffered domestic violence to attend tailoring and sewing courses and involved at least 11 women in continuous training on techniques for crafting artisan jewellery, later engaged to produce a unique line of jewellery marketed on POGON. We developed a special jewellery line branded as “POGON – Unique”.

Work on capacity building of public institutions providing access to justice for citizens continued. We participated in the process for drafting the strategy and work program of the Commission for Prevention and Protection against Discrimination (CPPD), and organized an inception training for commission members. As part of the Anti-Discrimination Network, together with HOPS, we developed a performance report for the Commission for Prevention and Protection against Discrimination and recommendations to its improve its track record and ensure effective enforcement of the law.

Public awareness work in this period focused on the importance of fiscal transparency and the need for priority-based gender-responsive budgeting, including support for citizens and public institutions to promote fiscal transparency and achieve greater and lasting changes. We encouraged public debate and activism by securing information and education material in the field of fiscal transparency and priority-based budgeting, i.e. we published more than 650 pieces of information on ESE’s websites and social media handles, with an outreach of more than 1 million persons. We celebrated the International Access to Information Day, September 28^th, with debates organized by the Agency for Protection of the Right to Free Access to Public Information. Together with the Employment Service Agency and the Ministry of Labour and Social Policy, we engaged 988 citizens from four municipalities (Tetovo, Shuto Orizari, Prilep and Kumanovo) in evaluation of access to employment services and developed a platform for publishing the implementation status of active employment measures in 2021. In the next period, we continued cooperation with the Employment Service Agency, the Ministry of Labour and Social Policy and the Ministry of Health aimed at establishing civic participation mechanisms and building capacity of employees at these institutions. In addition, we initiated cooperation with the Ministry of Environment and Spatial Planning. The digital platform for publishing real-time information on implementation of ESA’s active employment measures and policies designed by ESE (as commitment under OGP) was officially launched in 2023.

We continued long-standing efforts to evaluate fiscal transparency and accountability of public institutions. In 2021, we assessed active and reactive transparency of 95 public institutions through continuous monitoring of official websites hosted by 25 public institutions and evaluating 1 690 procedures on free access to information. In the same year, we collected data on implementation of 3 130 public procurement procedures organized by 62 public institutions in 2020 and 2021 and drafted 63 proposals to promote cost-effectiveness, efficiency and transparency in public procurement. These data were presented to 63 public institutions. In 2022, we developed three reports based on reactive transparency assessment of 70 institutions by addressing them with 1 690 freedom of information requests in 2021 and assessed proactive transparency of 25 public institutions and cost-effectiveness and efficiency of 2 081 public procurement procedures implemented by 62 public health institutions in 2021. In 2023, we worked on building trust and sustainability of all initiatives aimed at promoting fiscal transparency and promoted the concept of openness in public procurement with 62 institutions providing services for citizens in the field of social and economic rights by monitoring their public procurement procedures and drafting recommendations to address challenges identified. Also, we worked on promoting access to public information, with special focus on information of significance for measuring gender equality and exercise of rights by vulnerable groups of citizens by initiating freedom of information procedures; we worked on educating the public and institutions about the right to free access to information, proposed measures and activities for public institutions aimed at increasing the scope of information made publicly available, and for measuring proactive and reactive transparency of institutions, followed by development of corresponding annual reports.

We advocated for improved fiscal transparency. In particular, we contributed in organization of OGP Ministerial Meeting as part of the Government of RNM’s regular session held on April 13^th, 2021. We announced the call for local governments to join OGP Local and helped the Municipality of Sveti Nikole to join this initiative in 2021. In the same year, we participated in development of several manuals, calls for proposals, rules of procedure, guidelines and indicators relating to development, implementation and monitoring of OGP Action Plan and performance of OGP working groups and OGP Coordination Council. ESE is member of the Governing Board of the OGP Civil Society Network and its representative was selected to serve a second term as member of OGP National Stakeholder Fourm. Moreover, we delivered training for 40 representatives from public institutions and civil society organizations involved in developing OGP 2021-2023 National Action Plan  and, together with FOSM and the Centre for Civil Initiative, supported implementation and monitoring of OGP 2021-2023 Action Plan. The association co-chaired the OGP Council in the period 2021–2023 and coordinated the process for co-creation of civic participation measures and activities under OGP 2023-2026 Action Plan. ESE is part of the Europe Beneficial Ownership Leadership Group that has made significant contribution to promoting civic engagement in the country and will continue to work jointly on furthering civic participation across Europe (under the OGP process).

Today, as the local self-government units in the Republic of North Macedonia have become financially independent and are increasingly reliant on the regular payment of fees by the local population, the cooperation and involvement of citizens in the decision-making and budgeting processes at the local level have become prerequisites for their successful functioning. The failure to implement continuous and systematic measures aimed at involving citizens in the work of local self-government is the primary reason for the population’s low level of familiarity with the functioning and organization of local self-government, their lack of awareness of the local budget process, their non-involvement in the preparation of municipal budgets, the lack of information regarding the documents prepared within the budget process, and the overall low level of trust and satisfaction with the work of local authorities.

Even after 22 years of independence, the Republic of North Macedonia has not yet established a legitimate, continuous, and non-selective process for involving citizens in the operations of local self-government. That is, despite 15 years since the ratification of the European Charter for Local Self-Government and 8 years since the establishment of independent local self-government units, citizens in the Republic of North Macedonia are still largely regarded only as an electoral body. They are not actively engaged in the budget process or in decision-making processes at the local level, even though there are legal provisions that allow for such participation.

This document presents the current situation regarding citizens’ participation in the decision-making and budgeting processes in the municipality of Tetovo. The findings presented are based on data collected from a survey conducted on a sample of 502 respondents in 2012. During the survey, citizens shared their views on three key areas: their familiarity with the organization and functioning of local self-government, their understanding of the municipal budget and the local budget process, and their perspectives and experiences regarding participation in the local budget process.

Public budgets and expenditures in Southeast Europe are often utilized by political parties in power as a means to advance their political priorities and finance actions that will help secure their re-election. In the process of setting budget priorities, the real needs of citizens are often marginalized and relegated to a secondary position. Public health, as a key public function, is frequently sidelined. When it comes to allocating funds for public health, governments usually concentrate on financing visible activities such as medical equipment procurement, employment, or reconstruction, often leading to the presence of corruption in the public health sector.

As a result, citizens—including those who use drugs and/or live with HIV—consistently face barriers when accessing public services, particularly healthcare services. These barriers often arise due to how governments prioritize and allocate funds for public policy implementation. Harm reduction services in Southeast European countries are typically viewed as non-priority services. Governments perceive financing these services as potentially damaging to their political success, without considering the needs of service users. Consequently, harm reduction services have, for years, depended entirely on funding from foreign donors (such as the Global Fund) without receiving adequate financial support from national budgets. In many cases, only minimal funds have been allocated for their continuation. This approach raises concerns about the long-term viability of these services, especially as foreign donors begin to reduce or completely withdraw their funding.

Improper allocation, poor prioritization, abuse, and mismanagement of public funds present significant challenges to the efficiency and effectiveness of harm reduction services.

This manual serves as a guide for civil society organizations on how to proceed in the event that foreign donors withdraw from financing national harm reduction programs. It is designed to help civil society organizations find resources within limited national budgets to ensure the financial sustainability and continuation of harm reduction programs after the Global Fund withdraws. The manual is structured to be practical and meet the needs of these organizations, helping them identify budget programs where funds are consistently underutilized, overestimated, or mismanaged. Additionally, it outlines strategies for redistributing existing funds, introducing additional income sources into the budget, or advocating for increases in the existing allocations.

Civil society organizations in the Republic of North Macedonia play a key role in promoting openness, participation, and transparency within the budget system and budget process. Therefore, their involvement in the budget process is essential and crucial for providing independent assessments and analyses. This, in turn, contributes to the development and sustainability of the budget system by presenting new information in budget debates and deepening those discussions through budget simplification.

To effectively influence budget priorities and processes, civil society organizations must deepen their engagement in the interpretation and analysis of budget data, thereby giving greater weight to their analyses and proposals. This manual aims to enhance the capacity of civil society organizations by equipping them with the skills needed to analyze and interpret budget data, which will help strengthen their role in budget advocacy. The manual introduces civil society organizations to the basic procedures for analyzing budget data from different perspectives throughout the budget process, with a particular focus on encouraging their direct involvement.

While the manual focuses on the national budget, the procedures outlined within it can also be fully adapted and applied to the analysis of local budgets.

Proactive transparency refers to the publication and accessibility of documents and information about the operations of public institutions without the need for citizens to request it. In contrast, reactive transparency involves providing information about the operations of a public institution only after a formal request for access to public information has been submitted. In essence, reactive transparency involves following the procedures established by the Law on Free Access to Public Information.

Since 2013, ESE has implemented a methodology for evaluating the levels of both reactive and proactive transparency in public institutions that directly or indirectly provide funding and make decisions affecting access to public health services. Through these analyses, ESE seeks to present the level of proactive and reactive transparency within certain public institutions, as well as to identify any changes in this area over the years. These analyses also provide guidelines for the institutions on how to achieve higher levels of proactive and reactive transparency through the publication of key budget and program documents, as well as the advancement of practices related to the implementation of the Law on Free Access to Public Information. It is important to note that these analyses are not intended to evaluate the quality of the published or otherwise provided information.

In 2021, 72% of the monitored institutions showed an increase in the amount of information and documents published on their websites compared to 2014. However, only one institution in 2021 was rated as fully proactively transparent: the Delčevo local government. This institution published a significant portion of program and budget information of importance to the public (80% of the 16 monitored documents/information). Delčevo local government was the only fully transparent institution among the 25 monitored, publishing more information than even the Ministry of Finance, which had held the top spot for proactive transparency for the previous two years.

In 2022, six out of 25 institutions were classified as partially proactively transparent. This figure reflects no change from 2021, as 11 institutions had been classified as partially transparent in that year as well. Meanwhile, 72% of the 25 monitored institutions (18 institutions) were classified as non-transparent in 2021.

Regarding reactive transparency in 2021, more than half of the observed institutions (a total of 40) provided information in response to requests made under the Law on Free Access to Public Information, thus demonstrating reactive transparency. However, the number of institutions that did not respond to any submitted requests (i.e., those classified as reactively non-transparent) was relatively small, totaling eight institutions. Nevertheless, nearly one-third of the observed institutions (22 in total) faced challenges in adhering to the Law on Free Access to Public Information. The majority of the institutions classified as partially or non-transparent in their provision of information through formal requests under the Law fell into this category for two main reasons: either they exceeded the legally mandated deadline for providing the requested information, or they provided responses only after the initiation of an appeal procedure before the Agency for the Protection of the Right to Free Access to Public Information.

The total health expenditure in North Macedonia represents, on average, 7% of GDP, which is two percentage points lower than the OECD average (9%). These costs are continuously rising due to an aging population and challenging socioeconomic conditions. Most EU countries are also facing rising healthcare costs. Consequently, patients are seeing increases in their health insurance contributions, or they will face such increases in the future.

On average, states spend 29% of their total expenditure on public procurement, and public procurement in healthcare represents the second-largest share compared to other state functions (over 9% of GDP), such as education, economic development, security, public order, peace, etc. Public procurement is the process most vulnerable to corruption, and the risk is particularly high in the healthcare sector. Corruption in healthcare procurement can be mitigated through increased transparency in drug prices, more centralized purchasing, or joint initiatives to implement procurement through public health institutions.

Due to corruption in public procurement procedures, the loss to state budgets exceeds 6% of healthcare costs. Moreover, a third of citizens in OECD member countries believe that the healthcare sector is corrupt or very corrupt.

In 2016, the Association for the Emancipation, Solidarity, and Equality of Women (ESE) began conducting annual monitoring of public procurement procedures within public health institutions to identify problems within the procurement system and make recommendations for improving transparency. The goal is to enhance the efficiency and effectiveness of public procurements, improve the quality of services provided by public health institutions, maximize the impact of citizens’ money spent on healthcare, and ensure that citizens have access to essential health services.

This analysis provides an overview of public procurement procedures conducted by 62 public health institutions from 2016 to 2019. The practice of awarding contracts to a single company, the use of the “lowest price” as the sole selection criterion, and the absence of clear assessments of the impact of public procurement on end users all contribute to limiting citizens’ access to healthcare services.

The low level of fiscal transparency is a global problem that increasingly affects citizens’ access to basic social and economic rights. The COVID-19 pandemic and the global economic crisis have further exacerbated these challenges, particularly widening the gap between citizens and the public sector. North Macedonia has not been immune to this trend; due to its developmental stage, these issues are even more pronounced in comparison to other countries in Europe and around the world.

Over the past five years, fiscal transparency has been increasingly recognized as a key priority and necessity for the state. In response, a series of strategies and action plans have been prepared, and some permanent legal solutions have been amended. However, despite these policy changes, we are witnessing increasing levels of corruption and a deterioration in the living standards of citizens. This reflects the government’s insufficient will and capacity to implement and address the necessary requirements to improve transparency.

At the same time, various barriers continue to prevent citizens from effectively monitoring the work of institutions. Citizens face challenges in exercising their basic right to access information due to a lack of awareness of this right, difficulty understanding the information provided by public institutions, mistrust in the system and institutions, reluctance to engage in lengthy bureaucratic processes, and the absence of mechanisms that guarantee the protection of their right to access public information.

In North Macedonia, efficient mechanisms for monitoring budget execution and evaluating the efficiency and effectiveness of government policies remain absent. Public procurement processes also need significant improvement to ensure transparency, efficiency, and effectiveness while addressing allegations of corruption and violations of equal access and fair treatment of participants.

Our monitoring reports from 2011 to 2019 highlight that public procurement in the public health sector remains a gray area in North Macedonia. Over the years, the transparency in publishing information related to public procurement procedures has significantly decreased, and the competitiveness and availability of procurement opportunities for various companies have declined. Conversely, there has been an increase in the concentration of contracts awarded to a small number of companies, with significant deviations often identified between the planned expenditure and the actual value of concluded contracts in certain years.

According to findings from the proactive transparency reports on institutions monitored by ESE, the past seven years have seen an increase in the number of documents and information published on institutional websites. Significant progress has been made at the Ministry of Finance (from 44% of tracked documents and information in 2014 to 87% in 2021 and 75% in 2022), Delčevo local government (from 31% of tracked documents and information in 2014 to 66% in 2021 and 80% in 2022), the Agency for the Protection of the Right to Free Access to Public Information (from 25% in 2015 to 60% in 2021 and 73% in 2022), the Ministry of Labor and Social Policy (from 25% in 2014 to 60% in 2021 and 50% in 2022), and Kočani local government (from 19% in 2014 to 60% in 2021 and 23% in 2022). However, this increase in the publication of documents and information does not ensure consistency or continuous progress. In general, institutions in North Macedonia exhibit a low level of awareness regarding proactive transparency, as evidenced by the fact that their websites typically provide only 30% of the basic program and budget documents.

Regarding reactive transparency, ESE reports show that “institutions provide more information in response to requests for access to public information than they do proactively on their own initiative.” Institutions only partially comply with the Law on Free Access to Public Information, demonstrating limited transparency in their operations.

Persistent patriarchal values and prejudices regarding the role of women in the family and society remain a significant factor in the tolerance and minimization of gender-based violence. These attitudes often lead to blaming the victims themselves for the violence they suffer. Unfortunately, many of these views are held by representatives within institutional systems, contributing to the lack of confidence in the ability of institutions to provide timely, adequate, and quality support and protection for victims. Moreover, victims of violence are often insufficiently informed about their rights and the available mechanisms for protection. For these reasons, we believe that continuous information and encouragement for victims are essential parts of the process of providing help and support.

The guide for protecting women who have suffered domestic violence is part of a series of guides for women victims of violence, prepared within the framework of the USAID project on the legal protection of women, implemented by ESE in collaboration with Open Gate and the Margini Coalition. The guide encompasses three key components: improving judicial procedures in cases related to violence and discrimination against women, enhancing the legal framework that protects victims of violence and discrimination, and strengthening the operations of civil society organizations that provide legal assistance to women victims of violence and discrimination. These guides have been developed based on the experiences of victims of domestic violence, human trafficking, and sex workers, particularly regarding their access to competent institutions and the protection they receive.

In 2018, the state ratified the Council of Europe Convention on Preventing and Combating Violence Against Women and Domestic Violence and subsequently adopted the National Strategy for the Implementation of the Convention 2018-2023, along with the Law on Prevention and Protection from Violence Against Women and Domestic Violence (Official Gazette of RSM, No. 08-524/1 of January 27, 2021). Despite these commitments, it is concerning that the state has not established the necessary conditions for implementing the Convention at the national level. This is largely due to a lack of financial and human resources and the absence of essential measures to address long-standing systemic deficiencies. These include inadequate prevention of violence, low levels of public awareness, insufficient services to support women, poor coordination between institutions, the lack of a system for data collection, and weak monitoring and evaluation of policies. Moreover, the punishment of perpetrators remains lenient, further weakening efforts to address gender-based violence.

A shadow report on the implementation of the Council of Europe Convention on Preventing and Combating Violence Against Women and Domestic Violence was prepared by the Association ESE, Open Gate, and the Margini Coalition. This report was submitted to the Group of Experts on Action against Violence against Women and Domestic Violence (GREVIO), which monitors the implementation of the Convention by member states. The report highlights systemic deficiencies, as well as the specific needs of women who have suffered domestic violence, victims of human trafficking, sex workers, and the LGBTI population, in all areas covered by the Convention.

By submitting this report, we seek to increase pressure on the Government and relevant ministries to take meaningful actions to improve the institutional response and the overall position of women victims of gender-based violence.

Basic courts play a significant role in the system of protection against domestic violence, as the primary legal mechanisms for this protection are the civil court procedures for imposing temporary protection measures (TPM) and criminal court procedures for crimes resulting from domestic violence. Recognizing the need to improve judicial protection for women who have suffered domestic violence, ESE began implementing the methodology of judicial observation in 2014. This approach involves collecting data from ongoing civil and criminal proceedings, establishing closer cooperation and communication with basic courts, strengthening their capacities, and conducting direct consultation and joint advocacy activities.

This analysis identifies the barriers that prevent women from effectively utilizing civil and criminal court procedures for protection against domestic violence. Findings from the analysis of criminal cases involving domestic violence reveal that women, particularly vulnerable groups such as women from rural areas and ethnic minorities, are insufficiently informed about and underutilize court procedures for their protection. Among domestic violence victims in criminal proceedings, 80% are from urban areas, while only 20% are from rural areas. In terms of nationality, 78% of the victims are Macedonian, 12% Albanian, 5% Roma, and 5% from other ethnic groups. A major concern is the lack of punishment for certain forms of psychological and sexual violence as domestic violence. Although the Criminal Code criminalizes all forms of domestic violence (physical, psychological, and sexual violence), sexual violence and distinct forms of psychological violence often go unpunished.

Through judicial monitoring of cases involving violence against women, we promote access to justice and judicial protection for women who have suffered violence. This monitoring also contributes to enhancing the sensitivity, transparency, and fairness in handling these cases. However, many women withdraw their complaints, particularly in cases involving the crime of “bodily injury” (Article 130, paragraph 2 of the Criminal Code), the most common crime associated with domestic violence, which requires the victim’s consent for prosecution. Furthermore, victims often face re-victimization during the legal process. In 77% of cases where material and other evidence were presented, victims of domestic violence had to testify, even when the evidence of violence was clear.

Another concern is the lenient punishment policy applied to perpetrators of domestic violence. Out of 66 cases where a judgment was issued, only 10 resulted in prison sentences. This leniency is due to judges often overlooking aggravating circumstances and frequently applying sentence mitigation for perpetrators of domestic violence. The protection provided through TPMs is also limited by procedural barriers within the court system. Although these are urgent legal procedures with short deadlines, in practice, these deadlines are not consistently respected, and judges’ actions are not unified. The primary reasons for postponing court hearings include improper summonses for the perpetrators and requests by the perpetrators’ attorneys to prepare defenses.

Women are often unaware of their right to free legal aid and representation by a lawyer in these court proceedings, as well as other rights, such as the right to a companion during the procedure. The high standard of proof required in these cases is another challenge. Data from court observations indicate that the most commonly presented evidence includes testimony from both the victim and the perpetrator, as well as material evidence. It is particularly concerning that judges often require this evidence cumulatively, even though the urgency of the procedure and the need to protect victims should warrant a lower standard of proof for domestic violence cases.

We use the findings from this analysis to encourage broader discussions among judges about improving judicial protection in domestic violence cases. We also promote joint activities to strengthen the legal framework and individual aspects of civil and criminal court procedures for protecting victims of domestic violence.

In their quest to resolve the violence they endure and secure the necessary protection for themselves and their loved ones, women who have suffered violence expect competent institutions, particularly all relevant professional bodies, to act promptly, appropriately, and effectively. The police, the public prosecutor’s office, and especially the courts—particularly the judges—are integral parts of one of the pillars of protection: the criminal justice system. Access to justice, awareness of the legal avenues for resolving domestic violence, the length of legal procedures, the evidence required, the nature of the court’s decisions, and, most importantly, the type of punishment imposed on perpetrators are all indicators of society’s response to this type of violence. These elements reveal the level of protection offered to victims of violence.

To understand this better, in collaboration with several basic courts, we reviewed 33 completed criminal cases. We collected and analyzed data regarding the criminal protection provided to women who suffered domestic violence. The goal was to assess the courts’ actions and draw certain conclusions to send a clear message to perpetrators that this kind of violence is not tolerated and will be punished accordingly.

This initiative is part of ESE’s broader activities aimed at preventing and protecting against domestic violence. Through these efforts, we aim to enhance the efficiency and accountability of the courts in delivering criminal protection from domestic violence, while also raising awareness and understanding of the issue. Although physical, psychological, and sexual forms of domestic violence have been punishable in our country since 2004, judicial practice reveals that psychological and sexual domestic violence are still not being adequately punished. Domestic violence cases often go unpunished due to the withdrawal from criminal proceedings for crimes committed in the context of domestic violence. As a result, perpetrators do not receive the punishment they deserve—one that matches the gravity and circumstances of the violence. Justice is delayed in cases of domestic violence, and women who have suffered violence are forced to relive their trauma as they testify about the violence during criminal proceedings.

Given the seriousness of gender-based violence and its consequences, international public law recognizes violence against women as a serious violation of human rights and requires an active stance by states to promote, protect, and fulfill the rights of women who have suffered violence. The “principle of due diligence” establishes the standards for the conduct of competent state institutions and holds the state accountable for violence committed against women by state actors, as well as by third parties. More specifically, the “principle of due diligence” implies the fulfillment of the state’s obligations in several fields, namely: preventing violence against women, protecting women victims who have suffered violence, prosecuting perpetrators of violence, punishing perpetrators, and providing compensation and other types of reparations for women who have suffered violence.

In relation to the prevention of violence against women, it is of particular importance for the state to address the fundamental reasons for the occurrence of gender-based violence, as well as society’s perception of violence, including the elimination of prevalent traditional practices that require the subordinate position of women in society. Regarding the protection of women who have suffered violence, the state must provide adequate legal, psychological, social, and health assistance, as well as other types of aid and support for women, including the provision of free legal aid in civil court proceedings for the imposition of temporary protection measures (PMZ), increasing the possibilities for initiation and successful completion of these procedures by women who have suffered violence. An integral part of the provision of protection is the continuous and systematic education of those who provide protection, which is the foundation for the successful provision of such protection—a multi-sectoral and coordinated approach in offering these specified services.

Conducting an effective investigation into violence is essential to eliminating violence against women in society. Thus, the state should ensure the implementation of a detailed and timely investigation and should not delay the criminal procedure. Moreover, the state should take steps to strengthen the confidence of women who have suffered violence in the operation of state institutions. In order to adequately address violence against women, it is necessary to hold the perpetrators accountable, meaning they should be punished accordingly. The imposition of the legally provided punishments for the perpetrators in line with the gravity of the crime should achieve the purpose of the punishment, i.e., prevent the recurrence and commission of violence. This is the state’s responsibility in this segment of the procedure. Equally important is the provision of compensation for women who have suffered violence, corresponding to the severity of the injuries and damage suffered. In this regard, the state is expected to undertake the responsibility to compensate for the harm caused as a result of the violence endured by women.

The analysis of the legal framework and the institutional response to violence against women, the findings of which are presented in this publication, focuses on the treatment of institutions and the judiciary towards various forms of gender-based violence, such as domestic violence, human trafficking, and violence against sex workers, through the prism of applying the “principle of due diligence.” As reflected in the content of the analysis, significant weight is given to the issue of access to justice for women who have suffered violence, because access to justice, from the moment the violence occurs until its judicial resolution, is our current and future strategic determination. Hence, this publication offers content that provides a historical perspective on the development of legislation in relation to all types of gender-based violence, and it highlights key findings regarding the protection prescribed by these laws. More importantly, it explores what part of the prescribed protection is implemented and how it is realized.

We will use the findings of this analysis to affirm the necessity of establishing a gender-sensitive legal system that aligns with international agreements to which our country is a signatory. It is important to recall that the Committee responsible for monitoring the implementation of the Convention on the Elimination of All Forms of Discrimination against Women requires states to establish legal systems that respond and adapt to local needs and situations. These systems should be dynamic, participatory, open to innovative practical measures, and gender-sensitive, while, above all, addressing the growing demands for justice by women.

The civil and criminal systems for protection against domestic violence were formally established in 2004. The civil legal system, through the imposition of temporary protection measures (TPMs) against domestic violence, serves as both a preventive tool and an immediate protective mechanism for victims, aiming to stop the violence. Basic civil courts impose these measures based on proposals submitted either by the Centers for Social Work (CSWs) or by victims themselves, utilizing their own funds or by accessing free secondary legal aid under the Law on Free Legal Aid. Additionally, all forms of domestic violence, including physical, psychological, and sexual violence, are criminalized, with harsher penalties, including prison sentences, foreseen for offenders. Domestic violence-related crimes are generally prosecuted ex officio, except for “bodily injury” and “stalking,” which require the victim’s consent for prosecution.

Despite the existence of these mechanisms, there are substantial gaps in their practical implementation. For instance, the number of cases requiring TPMs significantly exceeds the number of motions actually submitted to civil courts. CSWs remain the primary actors initiating such court actions, as many women do not personally pursue court proceedings, either due to financial constraints or a lack of knowledge about free legal aid options. The response from CSWs often falls short due to delayed actions, improper treatment of domestic violence cases as “marital disputes,” insufficient risk assessments, and failure to consult with victims when proposing measures. Moreover, there is no established system for monitoring the enforcement of TPMs, which further impairs civil legal protection for women who have experienced domestic violence.

Criminal legal protection is similarly lacking, with shortcomings such as the failure to recognize specific crimes related to psychological and sexual violence, the reduction of domestic violence cases to minor offenses, ineffective investigations, lengthy court proceedings, and lenient sentencing policies for perpetrators.

Women who have suffered domestic violence also face considerable barriers in accessing legal aid and the judicial system to resolve related legal issues, including divorce, child custody and maintenance, property division, and compensation for damages. Women are often unaware of their rights to be exempt from court fees under the Law on Civil Procedure and to access free legal aid under the Law on Free Legal Aid. As a result, many do not exercise these rights, which could alleviate some of the financial burdens associated with pursuing legal remedies (ESE, 2021).

Data collected by ESE reveals that women who have experienced domestic violence are often financially disadvantaged due to medical expenses, lost work or reduced income, relocation costs, and other living expenses resulting from the abuse. These financial difficulties make it challenging for them to meet their basic needs and those of their children following separation or divorce. Compounding this issue, child support awarded by courts is often insufficient to cover the children’s needs and is either not paid or paid irregularly by the abusive parent (ESE, 2021).

The well-being of children, which is the primary objective of child support, is a multifaceted issue that must be examined from several perspectives. Effective child support policies should increase the financial and other resources available to children, eliminate obstacles that hinder consistent support, provide employment opportunities for the parent responsible for paying child support, support parents in actively fulfilling their parental responsibilities, and enable both parents to jointly perform their duties. This issue is particularly relevant for women who have suffered domestic violence, given their vulnerability and the consequences they continue to face. These women often confront additional challenges, such as the non-payment of child support, which further hinders their recovery and ability to fulfill their parental obligations.

Data from the Association ESE’s analysis, which draws on the experiences of women involved in court proceedings to secure child support, reveal that the awarded child support is often insufficient to meet the educational, recreational, and other needs of their children. Many women are forced to cover these expenses themselves because they do not receive any maintenance from the parent ordered by the court to provide support. Additionally, most women and their children face deteriorating living conditions after divorce or separation. Ten out of the seventeen women in the study, along with their children and the households they live in post-separation, do not have sufficient income, including social assistance, to meet their monthly living expenses. Furthermore, fifteen out of seventeen women do not receive the full amount of child support ordered by the court, if they receive any payments at all. In many cases, payments are delayed or only partially fulfilled.

The findings from this analysis highlight the need for improvements in judicial practices for determining child support amounts, such as taking into account children’s needs both before and after the divorce, as well as the parent’s additional income and other relevant factors. The analysis also underscores the importance of establishing effective mechanisms for enforcing child support payments from the responsible parent.

Women who have experienced domestic violence typically undergo multiple court proceedings to resolve issues related to domestic violence and other legal matters, such as civil proceedings for the imposition of temporary protection measures (TPM), criminal proceedings, divorce, custody and child support, property division, compensation for damages, and more. The judicial resolution of these legal matters is influenced by court fees and costs, as well as the financial ability of the women to pay them. Many women who have been or will be involved in civil court proceedings are not sufficiently informed about, nor do they fully utilize, the legal provisions available for exemption from court costs under the Law on Civil Procedure or the right to secondary legal aid under the Law on Free Legal Aid.

Data from an analysis conducted by the Association ESE with 30 women who were planning or had already undertaken civil court proceedings to address their legal challenges reveal a significant lack of awareness regarding court costs and their legally guaranteed rights. Out of the 16 women planning to pursue civil court proceedings, 12 were unaware that they needed to submit additional documentation alongside their requests for exemption from court costs, and only one woman was fully familiar with the required documents for exercising this right. Additionally, only one-third of the women knew that they might be required to compensate the opposing party’s costs if they lost their case. Furthermore, due to their unfavorable financial situation, many women cannot cover the court costs for all procedures, leaving some of their legal issues unresolved. Out of 14 women who had gone through court proceedings, 10 did not hire a lawyer, and most were unable to cover the associated court costs.

The findings from this analysis emphasize the need to provide women who have experienced domestic violence with more information about the types and amounts of costs involved in court proceedings, as well as their legally guaranteed rights. Moreover, the analysis provides evidence for the need to increase the use of exemptions from court costs and/or access to free legal aid for women in court cases aimed at resolving issues related to domestic violence.

Facilitating access to justice for women who have experienced domestic violence is a long-term strategic commitment of ESE. Providing free legal aid to these women is particularly vital for their effective use of protection mechanisms and judicial resolution of sensitive legal issues they face, such as divorce, custody, child support, property division, compensation for damages, and other legal matters. Addressing domestic violence through the courts or other competent institutions incurs various costs, including transportation, court fees for initiating proceedings and obtaining judgments, and administrative expenses. These costs further influence the dynamics and effectiveness of resolving sensitive legal issues. Given the limited financial resources for pursuing such court cases, women often lack access to the free legal aid they need to resolve their legal challenges.

The Cost-Benefit Analysis of Providing Free Legal Aid to Women Victims of Domestic Violence 2017–2022 provides data on the costs incurred by women as they take legal action to address domestic violence and related issues. It also details the costs borne by organizations providing such services, the time women spend seeking legal assistance, their level of satisfaction with ESE’s legal services, and their experiences, including the stress they suffer while dealing with the institutions involved in resolving their issues.

The findings from this analysis demonstrate the significant contribution of civil society organizations in providing legal aid and support to domestic violence survivors. It also underscores the need for the state to increase funding for secondary legal aid and provide long-term financial support to CSOs offering these services.

According to a national survey on legal (“judicial”) issues conducted in Macedonia (Srbjanko et al., 2013), nearly half of the population (49%) reported experiencing at least one legal problem in the previous three years. A large proportion of respondents faced more than one legal problem during the analyzed period. The most frequently reported issues were related to housing and property disputes, which accounted for approximately a quarter of all reported problems. Other commonly reported issues included employment, consumer protection, and financial disputes.

Two-thirds of the respondents who experienced legal problems reported taking action to resolve them, with about one-third seeking legal advice. Most of these individuals sought advice from family, friends, colleagues, or partners. However, one-fifth were dissatisfied with the advice they received, and two-thirds had to pay for legal assistance. Notably, a significant portion of respondents (20%) did nothing to resolve their legal issues due to a lack of financial resources. The groups least likely to take action included the poorer, younger, unemployed, and ethnic Albanians.

Furthermore, more than half of those who took no action cited a lack of confidence in the availability of legal assistance. The likelihood of resolving the problem was lower when the opposing party was the Government or an employer, as compared to issues involving private organizations, family members, partners, or others. This finding suggests a greater need for assistance in cases involving power imbalances. Less than 10% of respondents involved in legal disputes had engaged in legal proceedings.

These challenges highlight the limited access to free legal aid, which is critical for resolving citizens’ legal problems, particularly for vulnerable groups. There is a significant gap between the number of citizens facing legal issues and those who have utilized free (secondary) legal aid under the Law on Free Legal Aid. Civil society organizations (CSOs) play a crucial role in bridging this gap by providing free legal aid and paralegal support to vulnerable groups. However, their contributions are insufficiently recognized, and the financial support provided by the state is inadequate.

This analysis emphasizes the importance of expanding free legal and paralegal assistance modalities through CSOs to better support vulnerable citizens. The data in this publication highlight the costs incurred by citizens, the overall expenses related to the provision of free legal aid, satisfaction with CSO services, and the stress experienced by citizens as a result of their legal issues and interactions with institutions involved in resolving their problems.

With the establishment of the new goals for sustainable development within the 2030 Agenda, access to justice for all, including the most marginalized, has been recognized as a separate goal for the first time. Under Goal 16, which aims to “promote peaceful and inclusive societies for sustainable development, ensure justice for all, and build effective, accountable, and inclusive institutions at all levels,” Sub-goal 16.3 specifically addresses “promoting the rule of law at national and international levels and ensuring equal access to justice for all.” This sub-goal requires states to incorporate access to justice and legal empowerment initiatives into strategies for economic growth, development, and poverty alleviation.

The general conclusion is that North Macedonia is lagging in fulfilling its obligations. The state has not taken concrete steps to implement the sustainable development goals, particularly in ensuring access to justice for vulnerable groups. The Government has not made efforts to inform relevant stakeholders or include them in the process of implementing and monitoring these goals. Additionally, there is a lack of publicly available data on the progress of implementing these goals in the country. The Government has not initiated the process of preparing a plan to achieve the goals, nor has it integrated economic, social, and environmental development into its policies. Furthermore, the Government has failed to allocate adequate financial, human, and technical resources for achieving these goals, particularly for ensuring access to justice for all. Vulnerable groups of citizens continue to face serious barriers in accessing justice and resolving legal problems, which the state neglects.

Moving forward, the state must intensify efforts to implement the sustainable development goals. This will require mobilizing relevant stakeholders and initiating the process of creating an implementation plan. Special attention must be given to Sub-goal 16.3, ensuring that the specific needs and challenges faced by vulnerable groups of citizens in accessing justice are adequately addressed. This publication presents key findings from an analysis of the data collected based on the established indicators for monitoring the implementation of Sub-goal 16.3—ensuring the rule of law at both national and international levels and equal access to justice for all.

Many citizens in North Macedonia require legal assistance but cannot access it due to a lack of information and financial resources. This is especially true for the Roma population, who, due to long-term poverty, social exclusion, discrimination, and lack of education, struggle to exercise their rights. This situation negatively impacts their access to healthcare, with many Roma facing various obstacles and difficulties in securing their right to health. Marginalized groups, like the Roma, are in dire need of legal assistance because they constantly face challenges in exercising their rights.

Paralegal assistance helps bridge the gap left by formal legal services by offering support through trained community members who are not lawyers but possess the necessary knowledge to inform others about their rights. Paralegals, as community members, assist by providing advice, preparing written submissions (e.g., requests, appeals, objections), referring and accompanying individuals to relevant institutions, organizing meetings with local authorities, and conducting educational workshops to empower community members to exercise their legally guaranteed rights.

This publication highlights the experiences of paralegals and provides testimonies from individuals in the community who, with the help of paralegal support, have successfully resolved the everyday challenges they face.

The limited access to healthcare, poor health conditions, and discrimination that Roma communities face when trying to exercise their right to health inspired the Association ESE to develop a model for providing paralegal assistance and support within Roma communities in the Republic of North Macedonia. We believe that enhancing legal literacy and empowering Roma community members is crucial. By doing so, they can become actively involved in claiming their rights, which will ultimately improve their access to healthcare. In addition, ESE works with local Roma organizations, actively engaging them in resolving both individual and collective issues faced by the Roma community.

In 2011, the first paralegal assistance and support programs were launched within the KHAM organization in Delčevo and the Center for Democratic Development and Initiatives in Šuto Orizari. In 2012, an office for paralegal assistance and support was established within the Roma Resource Center (RRC) in Šuto Orizari. Later in 2013, another office was opened within KHAM in the village of Crnik in Pehčevo, followed by one in the Municipality of Vinica. ESE continues to support these local Roma organizations, providing continuous education and training to paralegals, enhancing administrative processes within the paralegal offices, and monitoring and evaluating their work.

This publication offers more details about the establishment of paralegal assistance and support programs, the support provided by ESE, and the positive outcomes of our work in this field.

Globally, approximately two-thirds of the world’s population faces limited access to justice. Specifically, 4.5 billion people cannot exercise their legally guaranteed rights, 1.5 billion people cannot resolve their everyday criminal, civil, or administrative legal issues, and 253 million live in extremely unjust conditions. Various factors contribute to these challenges, both on the supply side (those providing services) and the demand side (those using services). Common issues include distance, social conditions, relationships related to legal needs and their resolution, costs of providing services, insufficient capacity to meet service needs, and the digital divide.

North Macedonia is no exception. In the 2023 Rule of Law Index, the World Justice Project ranks the country 67th regarding adherence to fundamental democratic values and the rule of law. The Rule of Law Index is widely regarded as the leading source of original and independent data on the rule of law across the globe.

The only national survey on legal problems in North Macedonia (Srbjanko et al., 2013) indicates that while half of the population has faced at least one legal issue in the last three years, effective resolution remains elusive. A lack of financial resources, mistrust in institutions, and obstacles to exercising legally provided rights hinder citizens’ ability to resolve their legal problems. Vulnerable groups—such as the poor, youth, women, the unemployed, and ethnic minorities—are in an even worse position, struggling to address the growing legal challenges they face.

Civil society organizations (CSOs) have traditionally provided legal and paralegal assistance to various marginalized and vulnerable groups, helping to bridge the gap in access to justice. However, these organizations face serious challenges, both in sustaining these services and in their overall functioning. Key issues include insufficient state financial support, the lack of legal recognition for the concept of providing paralegal assistance and support, and inadequate ongoing education for paralegals. These challenges are particularly pressing for CSOs that work with marginalized and vulnerable communities.

Employment Agency collects, on an annual level, an average of 13.6% more revenue than the planned amount and spends 25.6% less than the total amount of realized revenue. From 2014 to 2018, there was a significant increase in the funds that EA transfers from the RNM budget to UNDP for implementing employment programs, measures, and activities. In 2014, no funds were planned to be transferred from the RNM budget to UNDP, but by 2016, 49,400,000 denars were planned for transfer, increasing to 541,247,050 denars in 2017, and remaining high at 405,881,283 denars in 2018. Despite this increase, UNDP’s participation in financing active employment programs, measures, and services has decreased drastically over the last five years. In 2018, there was a significant reduction in funds allocated for implementing active employment programs, measures, and services compared to 2017—a decrease of 437,206,282 denars or 44%. Additionally, each year the Agency faces unpaid obligations to executors involved in implementing the Operational Plan, averaging 24,412,370 denars. In 2018, unpaid obligations increased by 16% compared to 2017, with 46% of them attributed to UNDP. On average, 2,199,780 denars are allocated annually for promoting employment measures, programs, and services. In 2017, when funds for promoting these programs were last planned, the Agency allocated 158% more than the previous year and 76% more than in 2014. However, despite this increase in promotional spending, 83% of the unemployed persons surveyed were unaware of the employment opportunities provided by the Operational Plan.

More than half of the unemployed citizens (63%) surveyed across the four municipalities have been long-term unemployed, meaning they have not been employed for more than four years. Access to active employment measures, programs, and services remains severely limited for the citizens of Bitola, Tetovo, Strumica, and Sveti Nikole, with only 54% registered in the EA records, half of whom are women. Almost half of the unemployed citizens who are unregistered in EA cannot remember when they last registered, while 37% have not been registered for two or more years. More than half of those who are registered with EA must re-register every 30 days to maintain their active job-seeker status. Additionally, approximately one-quarter of those registered faced challenges during registration. Among the registered unemployed, 74% (including 71% of women) were unaware of their right to access employment measures, programs, and services. Of the 112 people who knew of their rights to access such programs, only 37% were aware of the specific measures, programs, and services available. Among the 112 people aware of these rights, only four (three of whom were women) utilized any of the available employment measures, programs, or services.

The analysis “Whether and how much citizens feel benefit from the implementation of active measures, programs, and employment services” is structured in three chapters. The first chapter is divided into two parts: the first part reviews the financial operations of EA, illustrating income and expenses in the period from 2014 to 2018, and the second part provides an overview of the movement of funds allocated for implementing active employment programs, measures, and services during the same period. The second chapter discusses the programmatic and budgetary implementation of three key employment programs for which the largest amount of funding is allocated annually from the Agency’s budget: the Self-Employment Program (component 1.1.1 of the Operational Plan for active employment programs and measures for 2017), the Subsidized Employment Program (component 2.3. of the same plan), and Employment Services of the Agency (component 6). The third chapter is divided into two parts: the first presents an evaluation of the quality, familiarity, usefulness, and accessibility of measures, programs, and services as perceived by unemployed persons covered by field research across 11 settlements, and the second part presents the assessment of employed persons who found jobs as a result of using these programs, measures, or services.

More than half of the unemployed citizens (63%) in the four municipalities covered by the research are long-term unemployed. About a quarter of those registered in the unemployment register of the Employment Agency of the Republic of North Macedonia (EA) faced difficulties during registration. Furthermore, 74% of registered unemployed persons are unaware that they have the right to access employment measures, programs, and services. Of those who do know, only 37% are informed about any of the available measures, programs, or services. Additionally, the number of people who have utilized any employment program, measure, or service in these municipalities is quite small. Programs for self-employment and subsidized employment have been evaluated by the International Labor Organization as either only partially meeting or not meeting their objectives.

The analysis, titled “Do the active measures, programs, and employment services implemented by the RNM Government reflect the real needs of citizens and contribute to improving their access to the labor market and increasing employment?” is divided into three chapters. The first chapter has two parts: the first part provides an overview of the financial operations of the Employment Agency (EA), focusing on the income and expenses in its budget between 2014 and 2018. The second part offers an overview of the funds allocated for implementing active employment programs, measures, and services during the same period.

The second chapter addresses the programmatic and budgetary implementation of the three largest employment programs, measures, and services funded annually by the Agency’s budget: the Self-Employment Program (Component 1 of the Operational Plan for Active Programs and Measures for Employment and Services in 2018), the Wage Subsidy Program (Component 2.1 of the Operational Plan for 2018), and the Employment Services of the Agency (Part II of the same Operational Plan).

The third chapter is divided into two parts. The first part presents an assessment of the quality, familiarity, usefulness, and accessibility of employment measures, programs, and services based on field research conducted in 15 settlements across four municipalities (Bitola, Tetovo, Sveti Nikole, and Strumica). The second part presents an assessment from employed persons who benefited from a program, measure, or service.

Since 2017, the Association ESE has conducted annual monitoring of the implementation of active employment programs, measures, and services, while enabling women from vulnerable categories to participate in evaluating their effectiveness.

At the end of 2019, the activity rate of the able-bodied population in the Republic of North Macedonia (RNM) stood at 57.5%, while the unemployment rate was 17.3%, significantly higher than the EU 27 average unemployment rate of 6.7%. Among women in RNM, the unemployment rate was 7.4% of the total active population, which is 1.4 percentage points higher than the EU 27 average (7%). The rate of inactivity among women in 2019 also increased compared to that of men.

The state allocates an average of 0.16% of GDP to active employment policies, which is well below the EU average and represents roughly 20% of the budget allocated to employment programs, measures, and services. These active employment policies primarily target unemployed persons registered with the state employment system. Unemployed persons who are not registered—constituting 55% of the total unemployed—do not have access to active employment measures, programs, and services. This restriction disproportionately affects women, who often remain outside the labor market due to their inactive status and the lack of measures designed to stimulate their participation.

In 2018 and 2019, active employment policies in RNM included four main categories of measures: 1) Direct job creation; 2) Employment stimulation; 3)Employment training; and 4)Community work.

Additionally, the annual operational plans for active employment policies included direct services for the unemployed. Data show that women are mainly targeted by policies aimed at stimulating employment but are underrepresented in other active employment measures and services.

This analysis aims to provide an overview of women’s status in the labor market and national active employment policies, with a particular focus on active employment measures and services. It identifies obstacles to women’s access to these measures and services and offers specific recommendations for future policy design. The analysis is based on publicly available data prepared and published by relevant national and international organizations from 2015 to 2019. Due to the scarcity of publicly available data on women’s participation in each phase of implementing active employment measures and services, some data were acquired through procedures for free access to public information.

Since 2017, the Association ESE has conducted annual monitoring of active employment programs, measures, and services, involving women from vulnerable categories in evaluating their implementation. This analysis reviews the barriers women face in accessing the labor market and provides decision-makers with guidance on addressing these challenges. The analysis also tracks changes in this area from 2015 to 2019.

At the end of 2022, the activity rate of the able-bodied population in the Republic of North Macedonia (RNM) was 55.2%, while the unemployment rate stood at 14.4%, significantly higher than the European Union average of 6.2%. The unemployment rate for women in RNM represented 5% of the total active population, with the rate of inactivity among women increasing compared to men in 2022. Women made up less than half of the total active labor force (39% on average), almost 20 percentage points (pp) lower than men.

More than half of the female population was inactive (average 64%), 28 pp higher than men. A noteworthy trend in 2022 was that although the overall unemployment rate decreased by 2.2 pp from 2019, the unemployment rate for women decreased by 7 pp.

However, the way active employment policies are currently designed and implemented does not contribute to improving employability or employment across the board. Limited access to these policies primarily results from a lack of confidence in their ability to help unemployed individuals find jobs. A 2019 study conducted by the Association ESE revealed that more unemployed citizens were unregistered (448 unregistered, of which 56% were women, compared to 361 registered citizens, of which 52% were women). The study also found that women were almost as informed about their rights related to active employment policies as men (31 women out of 60 respondents knew they had rights). Still, only three women used an active measure or program for employment. Importantly, of the 818 citizens surveyed in 2019, only six were employed as a result of active employment policies, three of whom were women.

Active employment policies apply to all registered unemployed citizens in the records of the Employment Agency (EA). However, the agency’s approach to including unemployed citizens is not structured to effectively target those who genuinely need work or to ensure equal access for women and young people.

Unemployed individuals who are not registered with Employment Agency are not covered or targeted by active employment policies and do not have the opportunity to benefit from them.

Regarding the right to employment, the situation is similar to that in other public sectors, with a significantly low or almost non-existent culture of citizen participation in preparing and implementing employment policies. This lack of participation stems from a lack of knowledge and skills, particularly among women. The absence of these skills limits citizens from fulfilling their roles and raising their voices before decision-makers, who benefit from this situation. Public employment policies fail to integrate a gender perspective due to the absence of gender-sensitive approaches. This situation leads to violations of employment rights, unequal access to the labor market for men and women, a lack of gender-sensitive policies, and the absence of policies that reflect the real needs of North Macedonian citizens. Ineffective budget utilization and inadequate planning of employment policies and measures are the key characteristics of the public employment system.

Public institutions responsible for planning and implementing employment policies and measures in North Macedonia are marked by high levels of closedness and lack of transparency. This opacity in public institutions and in the planning and implementation of employment policies and measures means that current policies do not reflect the real needs and interests of citizens, particularly women. Moreover, there is no culture of active citizenship, meaning that citizens are not actively involved in decision-making processes from beginning to end. This lack of participation is caused by non-functioning mechanisms for citizen engagement in decision-making and the absence of practices for mobilizing and empowering larger groups of citizens to engage independently in public processes.

Civil organizations in the Republic of North Macedonia play a crucial role in promoting openness, participation, and transparency within the budget system and process. Their involvement is essential for providing independent assessments and analyses that support the development and sustainability of the budget system. Civil society organizations contribute new information to budget debates and facilitate a deeper understanding of the budget through simplification and interpretation.

To effectively influence budget priorities and processes, civil society organizations must engage more deeply in interpreting and analyzing budget data. By doing so, they can add credibility to their analyses and proposals. When these organizations combine their knowledge of the challenges faced by communities in exercising their rights—such as access to health and education—with a thorough understanding of budgets and a solid advocacy strategy, they can positively influence decisions related to public policies. Additionally, by working closely with citizens and enhancing their capacity in relation to public budgets, civil society organizations can foster greater public participation in budget processes, especially at the local level.

To support this effort, we have prepared this manual, aimed at improving the capacity of civil society organizations by providing skills for analyzing and interpreting budget data. These skills will help strengthen their budget advocacy efforts. The manual is designed to familiarize civil society organizations with the basic procedures for analyzing budget data from various perspectives throughout the budget process and guide their direct involvement. It is particularly intended for civil society organizations working on budget-related issues that require the collection, analysis, and interpretation of budget data. The manual aims to equip these organizations with the tools necessary to understand budget data, hold decision-makers accountable, and enhance their ability to engage effectively in the budget process.

The COVID-19 pandemic has placed immense and unpredictable pressure on the global economy and public health systems. It has also amplified and exposed existing inequalities and discrimination, particularly among vulnerable groups. The pandemic has exacerbated gaps between men/boys and women/girls, ethnic minorities, and individuals from different socio-economic backgrounds. Beyond being a health crisis, the pandemic has triggered labor market disruptions and widespread socio-economic challenges, further threatening the livelihood of citizens, especially those from vulnerable and marginalized populations.

Given this, it is the responsibility of the state to implement a series of measures aimed not only at improving the health sector’s response to the pandemic but also at enhancing the well-being of citizens and ensuring their access to essential services. However, such measures require additional financial resources that were not initially accounted for in the state budget.

In this context, we conducted an analysis to evaluate three key aspects: the transparency of procedures for raising funds to address the COVID-19 crisis, the transparency of budget changes made by public institutions during the state of emergency, and the transparency of procedures for spending funds raised through public fees, donations, and grants.

The analysis revealed a complete lack of transparency in several areas. These include the collection of funds from public fees, donations, and grants intended for the COVID-19 response; decision-making and implementation of budget changes during the state of emergency; and the allocation and spending of budget funds designated for managing the pandemic.

Health care for mothers and children targets all women in the reproductive period (ages 15 to 49), as well as infants, young children, school-age children, and adolescents. Providing timely, adequate, and quality health care for these groups not only improves their immediate health and quality of life but also fosters appropriate early childhood development, ensuring long-term benefits for individuals, communities, and society as a whole.

Every year, the Ministry of Health implements a Program for active health care of mothers and children with several key goals: 1. Continuous improvement of the system for monitoring the health status of mothers and children and enhancing the efficiency of health care;2. Raising awareness and educating the population on healthy lifestyles and proper health behaviors in the preconception, antenatal, postnatal, and infant periods, with a focus on vulnerable categories of women (including Roma women, women from rural areas, and undocumented individuals); 3. Improving quality and equity in access to health services for mothers and children, particularly for vulnerable women; 4. Ensuring timely detection of diseases in newborns, infants, and young children; 5. Strengthening intersectoral cooperation and community partnerships to address the health challenges of mothers and children, with an emphasis on reducing barriers and increasing access to services; and 6. Guaranteeing timely and early access to quality antenatal health care for all pregnant women, removing geographic, financial, and cultural barriers, especially for vulnerable groups.

Recognizing the significance of this program for promoting the health and well-being of mothers and children, particularly within vulnerable communities, the Association ESE began annual monitoring of the program in 2011. This includes tracking both the implementation of activities and the program’s budget.

This analysis focuses on the budget review of the program for the period from 2017 to 2019. Despite an increase in the overall allocation of funds for this program during this time, it was found that the budget is subject to frequent changes throughout the calendar year, with the originally allocated funds often reduced. Additionally, inconsistencies were identified between the budget data reported by the program’s executors and the data provided by the Ministry of Health. Furthermore, although the total budget for the program has grown, the funds designated for vulnerable groups, particularly for activities targeting the Roma community, have been reduced.

Every year, the Government of the Republic of North Macedonia allocates funds through the budgets of the Ministry of Health and the Health Insurance Fund of Macedonia to implement measures and activities that ensure comprehensive health care for citizens. The Ministry of Health is responsible for preparing health policies, monitoring their implementation, setting health care priorities, allocating funds from the state budget, and overseeing the functioning of the health care system.

The work of the Association ESE has revealed that the Ministry of Health does not always efficiently plan or spend the allocated budget funds. This inefficiency has had a negative impact on the quality of health care and has limited access to essential health services, particularly for vulnerable populations. The consequences are evident in various forms: 203 women have died of cervical cancer over five years due to inadequate health policy implementation, patients regularly face problems such as a lack of gynecologists in primary care, unauthorized billing for services that are supposed to be free, and discrimination in the provision of health services.

This analysis examines how the government allocates and spends funds from the state budget to the Ministry of Health. It aims to understand the trends in health funding, changes in budget sources, and the ministry’s capacity to collect and spend these funds, as well as how these factors influence citizens’ access to basic social and economic rights.

One key finding is that, over a seven-year period, the Ministry of Health’s budget has consistently accounted for an average of 3% of the total state budget annually. This fixed allocation suggests that the government follows a simple mathematical distribution of funds across different public sectors, including health, rather than planning the budget according to citizens’ actual needs. This approach results in many citizens being excluded from the health system, forcing some to pay out of pocket for necessary health services. Moreover, the budget allocated for health care frequently changes during the year, decreasing by an average of 2.3% annually. Additionally, a portion of the health budget remains unspent each year, further limiting the effectiveness of health care delivery.

Assessment of the impact of macroeconomic policies on public health is crucial due to the numerous reforms being implemented. These reforms aim to expand the fiscal base, thereby increasing inflows into the state budget, fostering fiscal consolidation, and adopting measures affecting available public funds, with a particular focus on the public health system. This assessment is especially significant as the government pursues economic liberalization, attracts foreign direct investment, and encourages domestic companies to raise employee wages. These actions directly affect the state budget by providing subsidies and exempting companies from public fees, which are expected to contribute to sustainable economic growth and development.

Health indicators used to measure a country’s development reveal that in North Macedonia, at least 100,000 citizens lack access to one or more basic health services, while at least 40,000 citizens face significant financial difficulties due to personal health expenses. Citizens’ health is influenced by various factors beyond their control. Recently, this situation is increasingly viewed as a result of individual rather than collective irresponsibility, both globally and within North Macedonia.

The analysis reveals that the trend in public health expenditures does not align with the trend in collected public revenues in North Macedonia’s budget. Although tax revenues have consistently increased during the analyzed period, these funds have not been used to finance public health services. The health budget’s shortfall has been offset through direct transfers from the national budget. Additionally, the growth of public revenues does not coincide with the real growth rate of GDP, and health care funding has decreased despite GDP growth.

The findings suggest that to improve access to public health services, the government should focus on: Enhancing macroeconomic and budget planning to ensure that macroeconomic policy changes are accurately reflected in health funding; Improving capacity to increase the collection of projected public revenues and expenditures, especially in health; Promoting economic growth by increasing the private sector’s share in financing public functions, thereby reducing the burden on citizens; Ensuring the equal distribution of funds across various state functions; and Eliminating inefficient and costly expenses in health that have minimal impact, redirecting those resources towards improving the health sector.

Health indicators, which are considered a standard for measuring a country’s development, suggest that in North Macedonia, at least 100,000 citizens lack access to one or more basic health services, and at least 40,000 citizens face significant financial difficulties due to the personal expenses they incur when receiving healthcare. This indicates that citizens’ health is influenced by a range of factors beyond their direct control. Recently, both globally and in North Macedonia, this situation is increasingly explained as the result of individual rather than collective irresponsibility.

An analysis of public healthcare spending as a percentage of GDP in countries worldwide shows that North Macedonia ranks among those with the lowest public health expenditure relative to GDP. Although total health expenditure as a share of GDP has decreased, government health spending as a proportion of total health expenditure (through the Ministry of Health’s budget) has significantly increased over the past two decades. It rose from 59.6% in 1995 to just over 69% in 2008 and 2013 but fell again to 63.3% in 2014. Concurrently, the last decade has seen an increase in private health expenditure, from 30.8% in 2013 to 36.7% in 2014. These key indicators suggest that the state is not adhering to the basic principles of using the maximum available funds for healthcare financing or progressively increasing financial resources for healthcare.

Additionally, in the last decade, the Ministry of Health has consistently failed to allocate sufficient budget funds for preventive healthcare, particularly for programs crucial to improving the health of women, mothers, and children. These include cervical and breast cancer screening programs, the Program for Active Health Care of Mothers and Children, and the Program for Participation in Childbirth. This situation indicates that the health authorities and the state do not prioritize preventive healthcare.

The insufficient allocation of financial resources for healthcare has a direct negative impact on the health and well-being of the population, with particular emphasis on vulnerable groups. Due to the lack of financial resources for screening programs in North Macedonia, 40 women die each year from cervical cancer, while breast cancer remains the third leading cause of death among women. This situation also negatively affects the financial situation of citizens, as in 2018, 46% of households paid privately for health services, and 7% of households experienced impoverishment due to the costs they had to pay for healthcare.

This situation is largely due to the fact that healthcare budgeting is not based on the actual needs and priorities of citizens. Instead, it is calculated by the central government using certain mathematical formulas. As a result, the Ministry of Health cannot determine budgets for preventive programs based on needs and goals; it receives fixed amounts from the Ministry of Finance for each program and adjusts activities within those amounts. Unless this practice changes, healthcare and preventive care budgets will continue to fail to meet real needs. This will further contribute to inadequate disease prevention and a series of barriers to accessing health services, particularly for vulnerable and marginalized communities.

Cervical cancer accounts for 10% of all malignant neoplasms worldwide, making it the twelfth most common cancer overall and the fifth most common cancer among women. Each year, approximately 490,000 women, or 16 out of every 100,000, are diagnosed with cervical cancer, and around 9 out of every 100,000 women die from it. In North Macedonia, about 40 women die from cervical cancer annually.

Organized screening is the most effective method for the prevention and early detection of cervical cancer, allowing for the identification of precancerous changes or cancer in its early stages, often before any symptoms appear. This screening process involves relatively simple and inexpensive procedures, such as gynecological examinations with a Pap test. Detecting cervical cancer early allows for timely treatment, which can completely cure the condition and prevent it from significantly impacting a woman’s health or quality of life.

In North Macedonia, cervical cancer screening is conducted according to internationally accepted standards and protocols among women aged 21 to 59 who have not had a Pap test in the last three years. For a screening program to be considered successful, at least 75% of the target female population should be screened within a three-year period.

Recognizing the importance of screening for women’s health and well-being, the Association ESE began monitoring the Cervical Cancer Screening Program in 2012. This program is part of the Ministry of Health’s initiative for the early detection of malignant diseases. Every year, ESE’s monitoring highlights various issues related to the planning and implementation of the program. One of the major problems is the insufficient funding, which hinders efforts to cover 75% of the target population. Despite ESE’s ongoing advocacy for increased funding and improved implementation of the program, the Ministry continues to allocate the same budget year after year, with occasional reductions.

To bolster its advocacy efforts and inform health authorities about the significance of effective screening, ESE conducted an analysis to assess the impact of cervical cancer when detected at advanced stages. The analysis highlights the costs related to diagnosis, treatment, and palliative care for both the state and affected women. It also demonstrates that increasing financial resources for the screening program would save lives, improve women’s quality of life, and reduce overall financial costs.

According to the analysis, due to inadequate screening, approximately 40 women die each year, and 350 women undergo aggressive chemotherapy and radiation treatments at the Oncology Clinic. Diagnosing cervical cancer at an advanced stage costs women around 11 million denars annually, while the state incurs costs of at least 29 million denars per year. Investing in the screening program would save the lives of 40 women, spare 350 women from aggressive treatments, and reduce expenses by 40 million denars for both women and the state.

The right to health is a universal human right, enshrined in both international agreements and the laws of North Macedonia. The health of mothers and children, recognized as particularly vulnerable groups, holds special importance to the state, which is obliged to continuously enhance the health of these populations. This obligation aligns with the United Nations Sustainable Development Goals (SDGs), particularly Goal 3, which aims to ensure healthy lives and promote well-being for all ages. Specifically, Goal 3 emphasizes reducing maternal mortality, as well as newborn, infant, and under-five child mortality.

North Macedonia has experienced fluctuations in its infant mortality rate. The country saw a decade-long decline, reaching a low of 7.6 infant deaths per 1,000 live births in 2010 and 2011. However, beginning in 2011, the rate began to increase, peaking at 11.9 infant deaths per 1,000 live births in 2016, a level comparable to the rates seen in 2005 and 2006. Fortunately, a decline followed in 2017 and 2018, with infant mortality dropping to 9.2 and then 5.7 deaths per 1,000 live births, respectively.

Given the Association ESE’s commitment to improving women’s reproductive health and maternal and child health, ESE initiated work in 2016 to identify the causes behind the rising infant mortality rate. In 2018, ESE convened an expert working group consisting of specialists in statistics, public health, neonatology, patronage, gynecology, and obstetrics. This group produced an analysis of perinatal and infant mortality in North Macedonia from 2011 to 2017, which helped identify factors contributing to the rise in infant mortality during that period.

The findings from this analysis formed the foundation for the development of a National Action Plan with the primary objective of improving the health of women, mothers, and children and reducing perinatal and infant mortality.

The plan focuses on improving access to and quality of healthcare for these groups. It lays out seven strategic goals supported by specific measures and activities:
1. Identifying the factors and causes contributing to perinatal and infant mortality, particularly among high-risk populations.
2. Advancing health statistics and record-keeping to enable timely and continuous monitoring of maternal and child health, as well as perinatal and infant mortality.
3. Enhancing health education related to reproductive health, healthy pregnancies, and infant care, with a special focus on rural areas, adolescents, and marginalized communities such as Roma and Albanians.
4. Improving antenatal, perinatal, and postnatal healthcare systems.
5. Enhancing primary healthcare to better provide antenatal, perinatal, and postnatal care.
6. Improving secondary and tertiary healthcare systems to provide high-quality maternal and infant care.
7. Strengthening the role of nurses in providing care during the antenatal, perinatal, and postnatal periods.

This action plan aims to ensure that all citizens, regardless of their background or location, have access to essential health services that protect the lives of mothers and children across the country.

Cervical cancer represents 10% of all malignant neoplasms globally, ranking as the twelfth most common cancer overall and the fifth most common among women. Annually, about 490,000 new cases are registered, with approximately 16 out of 100,000 women developing the disease and 9 out of 100,000 dying from it. In North Macedonia, around 40 women die each year from cervical cancer. Organized screening is the most effective way to detect precancerous changes or cancer at an early stage in asymptomatic women. This screening relies on simple and affordable procedures, such as a gynecological exam with a Pap test, which can prevent the disease or detect it early enough to be fully curable. Early detection can prevent lasting consequences and maintain a woman’s quality of life.

International protocols suggest that screening should target women aged 21 to 59 years who have not undergone a Pap test in the last three years. For a screening program to be considered effective, it must cover 75% of the target population within a three-year span.

Given the importance of screening, ESE began continuously monitoring the Cervical Cancer Screening Program in 2012, which is a component of the Ministry of Health’s Early Detection of Malignant Diseases Program. Through our monitoring, we have uncovered several issues in the program’s planning, implementation, and oversight. Notably, the Ministry of Health allocates insufficient funds to achieve the 75% coverage target for women in the appropriate age group. Additionally, the program suffers from poor execution and coordination by those tasked with its implementation.

A major barrier is the insufficient number of family gynecologists, particularly in 45 municipalities where no such specialists are available. This shortage is significant since family gynecologists are responsible for conducting the Pap smears that form the basis of the screening. Furthermore, while the program mandates that all family gynecologists participate in screening, ESE’s findings reveal that many do not. These gaps in coverage, especially in municipalities lacking family gynecologists or among women whose gynecologists do not participate in the program, significantly impede access to screening.

As a result, screening coverage remains low, with only 25 to 28% of women being screened over a three-year period—far below the 75% needed for the program to be effective. In response to these challenges, ESE continues to monitor the program, identify shortcomings, and advocate for improvements by presenting our findings and recommendations to the Ministry of Health and the public.

This analysis covers the screening program’s implementation in 2020, during which only 5.6% of the target group of women were screened. This low rate, exacerbated by the COVID-19 pandemic, highlights the health system’s lack of preparedness to maintain essential screening programs during health crises, with serious consequences for women’s health and lives.

The right to health is enshrined in the Constitution and laws of the Republic of North Macedonia, as well as in international documents. According to the World Health Organization, the fundamental principles of primary health care (PHC) assert that all people everywhere have the right to the highest level of health and health care without difficulty. PHC ensures that health systems address individual needs and preferences, including health promotion, disease prevention, treatment, rehabilitation, and palliative care. It is considered the most inclusive, equitable, and cost-effective approach to achieving universal health coverage by ensuring that individuals receive the care they need when and where they need it, without facing financial or other barriers.

For 20 years, the Association ESE has worked to promote health and improve access to health care for the Roma population. Since 2011, in collaboration with partner Roma organizations, ESE has applied social accountability and legal empowerment approaches to strengthen and involve the Roma community in monitoring the implementation of health policies and services. These activities also focus on involving the Roma in policy and service creation to meet their needs, with a special emphasis on women’s reproductive health and maternal and child health, as evidenced through community-based research.

ESE’s work within the Roma community has highlighted the widespread difficulties the Roma population faces in accessing primary health care. Recognizing these challenges, in 2022, the scope of research within the Roma community was expanded. In addition to examining the barriers women, mothers, and children encounter in accessing health services, the research also aimed to identify obstacles faced by the broader Roma population in accessing primary health care and to determine their needs. The findings, rooted in the experiences of Roma communities themselves, should serve as a basis for planning and improving health care for the Roma population.

The research revealed that the Roma population in North Macedonia faces significant barriers in accessing primary health care services compared to the rest of the population. This disparity highlights the inequality in health care access between the Roma and the broader population, resulting in unmet health care needs and untimely care. Delays in receiving care have a profound impact on the health and quality of life of the Roma. Moreover, the barriers vary across different municipalities, indicating that not all Roma communities face the same challenges. The research report divides the findings into two key areas: 1) access to primary health care services for the Roma population, and 2) access to reproductive health services for women and to health services for mothers and children within Roma communities.

The right to health is protected by the Constitution and laws of the Republic of North Macedonia, as well as international documents. According to the World Health Organization, the fundamental principles of primary health care (PHC) emphasize that all people, everywhere, have the right to achieve the highest level of health and health care without difficulty. Primary health care aims to address the needs and preferences of each individual, including health promotion, disease prevention, treatment, rehabilitation, palliative care, and more. PHC is considered the most inclusive, fair, and cost-effective approach to achieving universal health coverage, ensuring that individuals receive care when and where they need it, without facing financial or other obstacles.

Through the long-term efforts of ESE to secure the right to health for the Roma community and other marginalized groups, numerous barriers and issues preventing the realization of primary health care for these communities have been identified and documented. The available data indicate that in North Macedonia, universal health coverage at the primary level has not yet been achieved for vulnerable and marginalized populations. Based on this, ESE conducted research to identify the challenges faced by the rural population in accessing primary health care and assess the extent to which the principle of universal health care at the primary level has been realized for this population.

The research focused on assessing barriers and needs within the rural population, with particular attention to women, mothers, and children as particularly vulnerable groups. Through surveys and focus group discussions, rural residents were given the opportunity to express the challenges and needs they face regarding access to primary health care. The findings of this research serve as a foundation for planning improvements in the primary health care system for rural populations.

The research revealed that the rural population encounters significant barriers in accessing primary health care services compared to those living in urban areas. This disparity in access, often determined by place of residence, results in untimely health care for rural populations, which negatively affects their health and quality of life. Additionally, there are notable differences in access to primary health care services among rural residents across different regions of North Macedonia.

The findings of the research are presented in two main parts:
1. Access to primary health care services for the rural population.
2. Access to health services for women’s reproductive health and for mothers and children from rural areas.

The health system in the Republic of North Macedonia is highly centralized at the national level, without consideration of the local conditions and needs. Health policies, budget planning, and management of the health system are primarily handled by national institutions, especially the Ministry of Health, the Health Insurance Fund, and the Ministry of Finance. This centralized structure leads to the inadequate addressing of the health care needs of all citizens, particularly vulnerable groups such as women, mothers, children, the rural population, and the Roma. As a result, disparities emerge in terms of the availability of health services, accessibility to them, and the financial capacity of citizens to receive these services. There is also a significant shortage of primary health care facilities, especially in rural areas and marginalized communities.

Inadequate planning is evident in preventive and primary health care. Insufficient funds are allocated to screening programs, and there is almost a complete absence of an organized approach to health education and health promotion for primary and secondary prevention of the most common chronic diseases in the country, such as cardiovascular and malignant diseases, which are the leading causes of death.

Long-standing issues regarding the health care of women, mothers, and children persist, leading to difficult access to health services. More than half of the municipalities in North Macedonia lack family gynecologists at the primary level, and there are very few pediatricians in primary health care practices. Additionally, rural areas face issues with the closure or inadequate functioning of vaccination points due to a lack of staff and equipment. These factors negatively impact access to reproductive health care, antenatal care, and health care for infants and children. The patronage service is also inadequate, with most women receiving only one or two visits during pregnancy and postpartum, instead of the scheduled five visits. In rural and Roma communities, the situation is even worse, with nearly half of Roma women not being visited by a health care nurse at all after childbirth, especially in marginalized Roma settlements.

Key preventive programs for women’s reproductive health, such as the Cervical Cancer Screening Program and the Breast Cancer Screening Program, have been plagued by issues for years. These problems include insufficient budget allocations, inconsistencies in implementation and coordination between service providers, and a lack of an adequate system for monitoring program implementation. Consequently, coverage of women with these programs is very low—only about 28% of the target group of women are covered by the Cervical Cancer Screening Program, and the Breast Cancer Screening Program has reached only 1-3% of the target population in recent years. Furthermore, the Ministry of Health has removed nearly all health education and promotion activities related to pregnancy, newborn and infant care, and children’s health (especially immunization) from the Preventive Health Care Program for Mothers and Children, even though these activities were regularly planned up until 2018. This has led to a complete absence of organized health education and promotion by the state for these groups.

These conditions have a severe impact on the health outcomes of women, mothers, and children. For example, approximately 40 women die from cervical cancer in North Macedonia each year, while over 300 women receive chemotherapy and radiation treatment at the Oncology Clinic—deaths and treatments that could have been prevented with timely detection through organized screening. Breast cancer is the fifth leading cause of death among women, with a death rate of 37 per 100,000 women in 2019—many of these deaths could also be prevented through appropriate screening. In recent years, child vaccination coverage has declined, with the coverage for the first dose of the MMR vaccine in 2021 at 70.4%, compared to 80.4% in 2015. The lack of health education and promotion, combined with barriers to accessing vaccination services, has contributed to this decline in vaccination coverage.

The rural population faces serious challenges in accessing basic health services at the primary level. One of the main issues is the lack of primary health care facilities in rural communities. For instance, only two rural municipalities have a family gynecologist, and many rural areas lack family doctors, pharmacies, vaccination points, or any form of primary health care services. Citizens from rural areas also face significant barriers in accessing these services, including inadequate public transportation, travel costs, lost time, poor road infrastructure, and the need for a companion, especially for children, the elderly, and chronically ill individuals. Research conducted by ESE has revealed that many vaccination points in rural areas have closed due to a lack of staff, and those that remain are inadequately staffed. Many rural settlements that once had family doctor surgeries and pharmacies now lack these services. ESE’s survey data show that 44% of the adult rural population do not visit a family doctor even when necessary, and 19% of minor children were not taken to a family doctor even when they had health issues. This situation has serious negative impacts on the health and well-being of citizens living in rural areas.

The Roma population is one of the most marginalized communities in the country. They face adverse social determinants of health, including poverty, unemployment, inadequate housing, and low levels of education. These unfavorable social determinants are compounded by barriers to accessing health care. In the municipality of Shuto Orizari, for example, there is an insufficient number of family doctors in primary health care, and the polyclinic there does not offer essential services like specialist consultations, X-rays, and laboratory diagnostics. In other municipalities, there is also a shortage of family doctors within Roma settlements. Roma citizens express high levels of dissatisfaction with the services provided by their family doctors—59% of the Roma population expressed dissatisfaction, according to ESE’s survey. All these factors contribute to the fact that 48% of the adult Roma population do not visit their family doctor even when they have health problems. These social determinants and barriers to accessing health care contribute to poorer health outcomes for the Roma population. Data shows that 50% of the Roma population dies before the age of 65, compared to 24% at the national level.